Development of Integrated Mental Health Services within pediatric ambulatory settings across an academic medical center

Abstract

Introduction: The need for child mental health services exceeds the availability of trained providers in The United States. Recent changes in health care policy have improved insurance coverage for mental health services, further increasing the number of children and adolescents seeking mental health treatment. With the national shift towards population medicine, it will be more imperative to integrate psychological screening and evidenced based mental health treatments into primary care and to develop efficient models of service delivery in the medical setting.Short description of practice change implemented: In response to these national trends and the local shortage of qualified pediatric mental health professionals, The Division of Child and Adolescent Psychiatry at The Penn State Milton S. Hershey Medical Center (HMC), in collaboration with the Department of Pediatrics, developed a Pediatric Psychiatry Collaborative Care Program (PPCCP). We provide services for both primary care and specialty pediatrics. Our goals include (1) improving access to behavioral health services (2) providing increased support to pediatric medical providers across the campus (3) improving the efficacy of behavioral health treatments offered in pediatric medical settings. The medical site completes brief consultation request forms that are reviewed by the mental health team. Patients are directed to HMC Behavioral Health Clinic if they are thought to have a serious emotional disturbance that would require emergent or long term treatment (e.g. schizophrenia, Bipolar Disorder). Parallel programs were developed for General Pediatrics and Specialty Pediatrics tailored to the needs of the specific patient populations. In both, patients are seen in the office of the medical provider.Key findings: The first program opened in General Pediatrics in April of 2014 and has been expanded several times. Pediatricians are given treatment recommendations that include diagnostic impressions, referrals for psychosocial treatments and, if indicated, clear guidance on beginning and titrating medications. Presently, we provide one clinic per week and are considering adding direct provision of brief psychosocial services in general pediatrics.The specialty pediatrics program began in the late summer of 2015 using a similar design except that it provides psychosocial services using a brief CBT model with the primary targets being internalizing symptoms and the challenges of coping with chronic medical disease. Provision of psychiatry consults was not deemed feasible as most psychotropic medications for these patients are prescribed by generalists outside of the HMC system and not the HMC specialists. All treatment at the specialty pediatrics program occurs in the multi-specialty pediatric clinic. Expedited referrals to our child psychiatry clinic are available for program participants. This program was expanded by adding a rapid screening service led by one of our departmental psychologists embedded in the pediatric GI clinic. Our program faced challenges during the pilot phase, including regulatory requirements for behavioral health, reimbursement issues, administrative staff turnover in the clinics, tracking billing claims and difficulties in changing practice habits of the primary care providers and psychiatrists. To address these concerns we completed an anonymous survey of providers in the General Pediatrics Clinic (response rate 66.6%). We found that 81.8 % providers referred patients to the Consultation clinic with 81.9 % finding the referral process easy, very easy or acceptable. Over 81% providers were satisfied or very satisfied with the quality of the written consultation and 63.6 % found the wait time shorter than what they expected.Highlights: After review of an anonymous survey and other verbal feedback, we expanded the program to offer brief treatment by PPCCP psychiatrists to optimize medication prior to transfer back to the primary care provider. Child Psychiatrists from our inpatient Consultation Liaison team now provide phone consultation, increasing the percentage of the work week that primary care providers can access a child psychiatrist. Different billing systems were developed for each setting to reduce the administrative burden on clinic staff and duplication of resources across departments.Conclusion: The availability of shared electronic medical records was essential to communication between psychiatrist and pediatrician. Other key components were invested leaders in Psychiatry and Pediatrics who met regularly to evaluate the program, identification of an administrative point person for each site who takes ownership of the program and the support of hospital administration who were willing to absorb some of the startup expenses. The program was recently recognized by a system wide award for the extraordinary patient experience and differentiating our health system. Using this model, we plan on expanding to select Family Medicine and other HMC General Pediatric sites outside of the primary medical campus and plan to increase targeted screening services in specific pediatrics specialty programs that are high utilizers of the PPCCP.